Discharge Planner/Case Manager RN

RN Discharge Planner Job Duties:

• Facilitates coordination and development of comprehensive and individual plan of care in collaboration with patient, family and multidisciplinary team to include goals and interventions relative to patient needs and choice. Coordinates and Prioritizes discharges daily in a timely manner. Makes patient/family rounds maintaining communication with all members of healthcare team. Reviews all tasks daily for follow up of assignment.

• On a concurrent basis assesses appropriateness of discharge disposition and communicates any changes in plan/needs with appropriate resources. Develops, implements, and manages processes for referrals to Home Health, HME, SNF, and other agencies/facilities. Promotes a timely, cost-effective, efficient, and safe discharge plan to community services including long-term care, home health services, etc. Tracks avoidable days on all patients as indicated. Assists staff in clinical decision-making and priority setting to ensure an optimal length of stay. Collaborates with: admitting office, HIM, patient accounts, and patient care departments to ensure effective and efficient communication of efforts and activities.

• Utilizes approved departmental communication tools for documentation. Acts as Liaison for interdisciplinary communication and coordination of discharge plan. Initiates Guardianship/APS/CPS referrals when appropriate and communicates with all necessary disciplines and agencies. Serves as a liaison for the physician/nursing staff/ancillary departments to implement processing of the patient through the healthcare delivery system. Proactively identifies and resolves delays and obstacles to discharge. Identifies appropriate venue for care within the continuum. Promotes a quality care environment while maintaining fiscal responsibility for resource conservation by promoting multidisciplinary practices. Dispenses the second copy of "The Important Message to Medicare Recipients" timely and according to CMS regulations.